Sarah Palin had a context, when she spoke. The context was the legislation before Congress.

Just now searching on this I find that by chance Sarah has just written further on this question:----------------Senator Reverend Ruben Diaz Chair, New York Senate Aging Committee Legislative Office Building Room 307 Albany, NY 12247

Thank you for asking me to participate in the New York State Senate Aging Committee's hearing regarding H.R. 3200, "America's Affordable Health Choices Act of 2009." You and I share a commitment to ensuring that our health care system is not "reformed" at the expense of America's senior citizens.

I have been vocal in my opposition to Section 1233 of H.R.3200, entitled "Advance Care Planning Consultation."[1] Proponents of the bill have described this section as an entirely voluntary provision that simply increases the information offered to Medicare recipients. That is misleading. The issue is the context in which that information is provided and the coercive effect these consultations will have in that context.

Section 1233 authorizes advanced care planning consultations for senior citizens on Medicare every five years, and more often "if there is a significant change in the health condition of the individual ... or upon admission to a skilled nursing facility, a long-term care facility... or a hospice program."[2] During those consultations, practitioners are to explain "the continuum of end-of-life services and supports available, including palliative care and hospice," and the government benefits available to pay for such services.[3]

To understand this provision fully, it must be read in context. These consultations are authorized whenever a Medicare recipient's health changes significantly or when they enter a nursing home, and they are part of a bill whose stated purpose is "to reduce the growth in health care spending."[4] Is it any wonder that senior citizens might view such consultations as attempts to convince them to help reduce health care costs by accepting minimal end-of-life care? As one commentator has noted, Section 1233 "addresses compassionate goals in disconcerting proximity to fiscal ones.... If it's all about obviating suffering, emotional or physical, what's it doing in a measure to 'bend the curve' on health-care costs?"[5]

As you stated in your letter to Congressman Henry Waxman of California:

Section 1233 of House Resolution 3200 puts our senior citizens on a slippery slope and may diminish respect for the inherent dignity of each of their lives.... It is egregious to consider that any senior citizen ... should be placed in a situation where he or she would feel pressured to save the government money by dying a little sooner than he or she otherwise would, be required to be counseled about the supposed benefits of killing oneself, or be encouraged to sign any end of life directives that they would not otherwise sign.[6]...(continued next comment)...

Sarah Palin letter to Ruben Diaz continued...--------It is unclear whether section 1233 or a provision like it will remain part of any final health care bill. Regardless of its fate, the larger issue of rationed health care remains.

A great deal of attention was given to my use of the phrase "death panel" in discussing such rationing.[7] Despite repeated attempts by many in the media to dismiss this phrase as a "myth", its accuracy has been vindicated. In the face of a nationwide public outcry, the Senate Finance Committee agreed to "drop end-of-life provisions from consideration entirely because of the way they could be misinterpreted and implemented incorrectly."[8] Jim Towey, the former head of the White House Office of Faith-Based Initiatives, then called attention to what's already occurring at the Department of Veteran's Affairs, where "government bureaucrats are greasing the slippery slope that can start with cost containment but quickly become a systematic denial of care."[9] Even Washington Post columnist Eugene Robinson, a strong supporter of President Obama, agreed that "if the government says it has to control health care costs and then offers to pay doctors to give advice about hospice care, citizens are not delusional to conclude that the goal is to reduce end-of-life spending."[10] And of course President Obama has not backed away from his support for the creation of an unelected, largely unaccountable Independent Medicare Advisory Council to help control Medicare costs; he had previously suggested that such a group should guide decisions regarding "that huge driver of cost . . . the chronically ill and those toward the end of their lives...."[11]

The fact is that any group of government bureaucrats that makes decisions affecting life or death is essentially a "death panel." The work of Dr. Ezekiel Emanuel, President Obama's health policy advisor and the brother of his chief of staff, is particularly disturbing on this score. Dr. Emanuel has written extensively on the topic of rationed health care, describing a "Complete Lives System" for allotting medical care based on "a priority curve on which individuals aged between roughly 15 and 40 years get the most chance, whereas the youngest and oldest people get chances that are attenuated."[12]

He also has written that some medical services should not be guaranteed to those "who are irreversibly prevented from being or becoming participating citizens.... An obvious example is not guaranteeing health services to patients with dementia."[13]

Such ideas are shocking, but they could ultimately be used by government bureacrats to help determine the treatment of our loved ones. We must ensure that human dignity remains at the center of any proposed health care reform. Real health care reform would also follow free market principles, including the encouragement of health savings accounts; would remove the barriers to purchasing health insurance across state lines; and would include tort reform so as to potentially save billions each year in wasteful spending connected to the filing of frivolous lawsuits. H.R. 3200 is not the reform we are looking for.

Thank you for calling attention to this important matter. I look forward to working with you again to ensure that we keep the dignity of our senior citizens foremost in any health care discussion.

I believe the great majority of Americans would still like for their doctor to be compensated for helping them with advice about treatment options in possible coming situations, ahead of time, in the last years of their lives.

We don't really want you to make it financially difficult for some of us to pay for advice, Sarah.

Neither would we like for you, Sarah, to decide we are unreliably able to choose for ourselves, freely, according to our own values, how we wish to live our final years, months, or weeks.

Instead, we, the majority, feel we ourselves are generally competent to decide this for ourselves.

And that's really rich comedy there, suggesting that "the majority" can decide things "freely." If you ever bothered to think about it, Hal, you'd realize that "majority" really only means something when it's being used as an excuse to deny some poor minority its own free choice. Think about it.

IMAC has precise duties, and those do not include a mandate to devise rationing to my knowledge. But...should IMAC do exactly that, it would then in turn be up to Congress and the President to choose whether to implement such an IMAC proposal. Any IMAC proposal is subject to the acceptance by Congress.

Do you think Congress will choose rationing?

I don't.

It's Congress that would have to decide on such, just as now, if IMAC is in effect.

and...if the minority of one wants for their insurance policy (Medicare, for which they paid taxes beforehand) to pay for an advanced directive consultation? Should a "majority", following Palin, be able to prohibit such an insurance benefit for this minority?

A: "Hal, you'd realize that "majority" really only means something when it's being used as an excuse to deny some poor minority its own free choice. "

B: "and...if the minority of one wants for their insurance policy (Medicare, for which they paid taxes beforehand) to pay for an advance directive consultation? Should a "majority", following Palin, be able to prohibit such an insurance benefit for this minority?"

There's a big difference between having the consultation for humanitarian reasons and having it because your "insurance company" wants to minimize how much you consume in benefits.

And the neat thing is that, like everything in a "public option," you can set it up on compassioniate grounds and then let the bean counters write the pamphlet -- like the VA's "Death Book." That was a huge success!

Insurance companies always want to minimize how much you consume in claims.

That's a constant.

So the question remains whether a majority in the Senate, whipped up by Palin, should be able to prohibit a benefit some sizable minority (or even majority) in the country would like to have on their Medicare insurance policy -- a consultation benefit for end-of-life counseling on treatment options.

You say: "...you'd realize that "majority" really only means something when it's being used as an excuse to deny some poor minority its own free choice. "

Part of the reason such a consultation with my doctor will someday be valuable to me personally is that I am not especially afraid of death. Instead, I am more afraid of having a lingering, uncomfortable hospital intervention where the outcome is really inevitable. Like Senator Kennedy recently, I'd rather be sailing, sitting at home, etc.

Sure I have *some* ordinary fear of dying, but not a strong, active fear. My life experiences have moved me past that.

So I actually see that kind of consultation as a positive -- it will give me more control of my own going, in my own way, according to what I like and value.

...

But...if I did have a strong, powerful fear of death -- which is a very commonplace human condition -- I'd have an entirely different feeling about such a consultation.

I'd dread and fear even the consultation, and it would discomfort me greatly to contemplate it.

I'd feel that even the suggestion of such a consultation was threatening.

Then I'd likely feel that it would be wrong, horrible to subject people to such a consultation if they were not ready for it.

So I'd want such consultations to be entirely voluntary.

Just like they were written in the proposed legislation -- voluntary.

Also, I think I can vaguely appreciate Palin's own feeling that some people would feel pressured even by talking with their own doctor -- as if that just the option that they could opt for less heroic care would create a kind of social pressure to choose other than what they would really want.

Now...to feel that way myself -- pressured -- I'd have to feel less autonomous, less able to form my own opinions and know what I think and feel independently of others.

But there are people who feel swayed and pressured by others' opinions quite easily I understand.

So I'm guessing at how they would feel...

...they might feel pressured just by a suggestion alone enough to ignore their own preferences, in the case where the doctor is incompetent or odd enough to not phrase options in a neutral way.

Therefore, it would make sense for any such consultation initiation to also be voluntary -- only initiated by the patient themselves, and not by suggestion of their doctor. This would avoid the situation where an individual that has little sense of self-determination would accidentally end up choosing wrongly for themselves.

Though I expect this was the intent of the proposal -- that such consultations be genuinely 100% voluntary in *every* sense -- it could be made explicitly clear in such a proposal that only a patient could initiate even the option of having such a consultation. There could be no phone call or letter from any provider or insurer to ask whether the patient wanted such a consultation.

Therefore, by that standard, no entity other than the patient, or their family or friends or articles they read, could suggest having such a consultation. They would have to come upon even the information about that option for having a consultation from independent sources other than their insurer or health care provider.